Quality Governance

1
Quality Governance

• New London Hospital Association, Inc.
• Terry LeBlanc, RN MBA CAPA
• Chief Clinical Officer

2
Who We Are
We are a critical access hospital in the Lake
Sunapee Region whose population is about 30,000
3
What We OfferHospital/Physician Practices

• Primary Care
• Outpatient Internal Medicine, Family Practice,
  Pediatrics and Gynecology, Rehabilitation (OT, PT
  and Speech Therapy)
• Lab Routine clinical and pathology
• Radiology Bone density, CT, Mammography, MRI,
  Ultrasound, and routine x-rays
• Inpatient Hospitalist Program, Medical,
  Surgical, Rehabilitation, Special Care,
  Sub-acute, Respiratory Care
• Secondary Care
• Ambulance, Cardiology, Coumadin Clinic, Dental
  Health, Dermatology, Diabetes Management, ER,
  Endoscopy and Colonoscopy, General Surgery, HTN,
  Infectious Disease, Infusion Therapies, Mobil
  Lithotripsy, Neurosurgery, Occupational Health,
  Oncology, Opthalmology, Orthopedics, Nutritional
  Counseling, Outpatient Psychiatry, Podiatry,
  Plastic Surgery, Pharmacy, Rheumatology, Sleep
  Lab, Stress test Echocardiogram, Urology

4
What We OfferClough Center

• Clough Center is a 58 bed Skilled and Long-term
  care facility.
• Part-time, Hospitalist model physician coverage
• Immediate access to a full-service hospital and
  emergency services
• Full service rehabilitation services available as
  needed
• SPA, Specialized Programs and Attention, program
  for residents in need of additional therapeutic
  environment support.
• A robust and meaningful activities program

5
Quality Steering

• The Quality Steering Committee of the Board and
  Medical Staff meets monthly to provide leadership
  and monitor performance of quality improvement.
• A trustee-physician (independent) chairs the
  committee.
• This committees minutes are included in board
  packets and the Board of Trustees receives
  quarterly updates.

6
Setting Aims

• Quality goals are set in two ways
• Annual quality goals specific facility wide
  goals
• Balanced scorecard higher level composite
  measures that include not only quality, but
  development, strategic planning, HR and financial
  measures as well.

7
Setting Aims

• Annual Quality Goals reported to the Quality
  Steering Committee of the Board on a quarterly
  basis
• Balanced Scorecard reported to the Board of
  Trustees on a quarterly basis

8
Learning Stories

• The Chief Clinical Officer presents a quality
  story at each Board of Trustees meeting. Stories
  illustrate where errors occurred and what has
  happened to improve the processes and systems
  associated with those errors to prevent them in
  the future

9
Changing the Culture

• With increased transparency, shifts in the
  culture are occurring moving us towards a more
  just culture.
• Quality Steering Committee of the Board leads the
  organization in this regard

10
Boards on Board

• Foundation for Healthy Communities and New
  Hampshire Hospital Association state-wide effort
  to strengthen Board Quality and Safety efforts
• Collaborative effort with Jennifer Chi and Jim
  Conway from IHI and Dartmouth Medical School
• Goals are
• Baseline assessment
• Benchmarking (other states)
• Educational and support tool kit
• Evaluation

11
Board Learning

• Education of the NLH Board occurs several ways
• New Board member orientation
• Clinical quality stories at Board of Trustee
  meetings
• Quarterly updates from the Quality Steering
  Committee of the Board to the Board of Trustees
• Monthly Quality Steering Committee of the Board
  meetings
• A comprehensive Annual Quality Report
• New England Healthcare Assembly Annual Trustee
  conference
• Dartmouth-Hitchcock Alliance Activities
• New Hampshire Hospital Association Activities
• Education sessions at Board of Trustee Meetings
  and Quality Steering Committee of the Board
  meetings

12
Executive Accountability

• Quality Improvement goals form the largest
  percentage of the incentive portion of executive
  compensation
• Composite quality measures as reported on the
  balanced scorecard are used as the quality
  measures

13

• Discussion